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Testimony: 

Before the Subcommittee on National Security, Emerging Threats, and 
International Relations, Committee on Government Reform, House of 
Representatives: 

United States Government Accountability Office: 

GAO: 

For Release on Delivery Expected at 9:00 a.m. EDT in New York, New 
York: 

Saturday, September 10, 2005: 

September 11: 

Monitoring of World Trade Center Health Effects Has Progressed, but Not 
for Federal Responders: 

Statement of Cynthia A. Bascetta: 

Director, Health Care: 

GAO-05-1020T: 

GAO Highlights: 

Highlights of GAO-05-1020T, a testimony before the Subcommittee on 
National Security, Emerging Threats, and International Relations, 
Committee on Government Reform, House of Representatives: 

Why GAO Did This Study: 

After the 2001 attack on the World Trade Center (WTC), nearly 3,000 
people died and an estimated 250,000 to 400,000 people who lived, 
worked, or attended school in the vicinity were affected. An estimated 
40,000 people who responded to the disaster—including New York City 
Fire Department (FDNY) personnel and other government and private-
sector workers and volunteers—were exposed to numerous physical and 
mental health hazards. Concerns remain about the long-term health 
effects of the attack and about the nation’s capacity to plan for and 
respond to both short- and long-term health effects in the event of a 
future attack or other disaster. 

Several federally funded programs have monitored the physical and 
mental health effects of the WTC attack. These monitoring programs 
include one-time screening programs and programs that also conduct 
follow-up monitoring. GAO was asked to assess the progress of these 
programs. GAO examined (1) federally funded programs implemented by 
state and local government agencies or private institutions, (2) 
federally administered programs to monitor the health of federal 
workers who responded to the disaster in an official capacity, and (3) 
lessons learned from WTC monitoring programs. GAO reviewed program 
documents and interviewed federal, state, and local officials and 
others involved in WTC monitoring programs. 

What GAO Found: 

Three federally funded monitoring programs implemented by state and 
local governments or private organizations after the WTC attack have 
provided initial medical examinations--and in some cases follow-up 
examinations--to thousands of affected responders to screen for health 
problems. For example, the FDNY medical monitoring program completed 
initial screening for over 15,000 firefighters and emergency medical 
service personnel, and the worker and volunteer program screened over 
14,000 other responders. The New York State responder screening program 
screened about 1,700 state responders before ending its examinations in 
2003. Most state responders have not been informed that they are now 
eligible to participate in the worker and volunteer program, and New 
York State responders could miss the opportunity for continued 
monitoring. These monitoring programs and the WTC Health Registry have 
collected information that program officials believe researchers could 
use to help better understand the health consequences of the attack and 
improve treatment. Program officials expressed concern, however, that 
current federal funding arrangements for long-term monitoring may be 
too short to allow for identification of all future health effects. 

In contrast to the progress made by other federally funded programs, 
the Department of Health and Human Services’ (HHS) program to screen 
federal workers who were sent by their agencies to respond to the WTC 
disaster has accomplished little and is on hold. The program—which 
started about one year later than other WTC monitoring 
programs—completed screening of 394 of the estimated 10,000 federal 
workers who responded in an official capacity to the disaster, but HHS 
officials suspended examinations and the program has not screened 
anyone since March 2004. The program’s limited activity and the 
exclusion of federal workers from other monitoring programs because of 
the assumption that they could receive screening examinations through 
the HHS program may have resulted in many federal responders losing the 
opportunity to identify and seek treatment for their WTC-related health 
problems. 

Officials involved in WTC health monitoring programs cited lessons from 
their experiences that could help others who may be responsible for 
designing and implementing health monitoring efforts that follow other 
disasters, such as Hurricane Katrina. These include the need to quickly 
identify and contact people affected by a disaster; to monitor for 
mental health effects, as well as physical injuries and illnesses; and 
to anticipate when designing disaster-related monitoring efforts that 
there will likely be many people who require referrals for follow-up 
care and that handling the referral process may require substantial 
effort. HHS and New York State officials provided comments on the facts 
contained in this testimony and GAO made changes as appropriate. 

www.gao.gov/cgi-bin/getrpt?GAO-05-1020T. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101 or bascettac@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting me to participate in today's hearing to discuss 
issues related to the health effects that people continue to experience 
in the aftermath of the September 11, 2001, terrorist attack on the 
World Trade Center (WTC).[Footnote 1] After the collapse of the WTC 
buildings, nearly 3,000 people died, and an estimated 250,000 to 
400,000 people who lived, worked, or attended school in the vicinity 
were affected. An estimated 40,000 people responded to the disaster, 
including New York City Fire Department (FDNY) personnel and other 
government and private-sector workers and volunteers from New York and 
other locations across the nation. These responders,[Footnote 2] as 
they took part in various rescue, recovery, and cleanup activities in 
the days, weeks, and months following the attack, were exposed to 
numerous physical hazards and environmental toxins due to the 
destruction caused by the attack. The magnitude and unprecedented 
nature of this event also exposed responders and many other people to 
considerable psychological trauma. 

Four years after the destruction of the WTC buildings, concerns remain 
about the long-term physical and mental health effects of the attack. 
Several recent studies of responders report that many of them have high 
rates of physical and mental health symptoms, of which respiratory 
problems are the most persistent physical effects.[Footnote 3] While 
the nature and severity of a future terrorist attack cannot be 
predicted, our prior work on the health effects of the WTC attack, the 
2001 anthrax attacks, and bioterrorism preparedness, as well as reports 
by other organizations, highlight the importance of ensuring the 
nation's capacity to plan for and respond to the short-and long-term 
health consequences likely to result in the event of a future attack or 
other disaster, such as the destruction recently caused by Hurricane 
Katrina.[Footnote 4]

As we testified in September 2004, in the aftermath of the WTC attack, 
five key federally funded programs were implemented to assess the short-
term, and in some cases long-term, effects on people's physical and 
mental health. These programs include the FDNY WTC Medical Monitoring 
Program, WTC Medical Monitoring Program (worker and volunteer 
program),[Footnote 5] New York State responder screening program, WTC 
Health Registry, and the Department of Health and Human Services' (HHS) 
WTC Federal Responder Screening Program. You asked us to provide 
information on the progress of these monitoring programs.[Footnote 6] 
My testimony today will focus on (1) progress made by federally funded 
programs that are implemented by state and local government agencies or 
private organizations and were established to monitor the health of 
people in the aftermath of the attack, (2) progress made by federally 
administered programs established to monitor the health of federal 
workers who responded to the disaster in an official capacity, and (3) 
lessons from WTC monitoring programs that could assist those who may be 
responsible for future disaster-related health monitoring efforts. 

To conduct this work, we obtained and reviewed program documents dating 
from the beginning of the programs, including grantee progress reports, 
budget documents, clinical protocols, health screening and other 
assessment tools, and selected peer-reviewed articles based on 
information collected by WTC monitoring programs. We also interviewed 
federal, state, and local officials and others involved in 
administering WTC monitoring programs, including officials from HHS and 
the Department of Homeland Security (DHS);[Footnote 7] New York State 
Department of Health; New York City Department of Health and Mental 
Hygiene; and FDNY. Within HHS, we interviewed officials from the Agency 
for Toxic Substances and Disease Registry (ATSDR); the Centers for 
Disease Control and Prevention's (CDC) National Center for 
Environmental Health and National Institute for Occupational Safety and 
Health (NIOSH); Federal Occupational Health Services (FOH);[Footnote 8] 
and the Office of Public Health Emergency Preparedness (OPHEP). We also 
obtained information from the Department of Defense (DOD) and the 
Department of Justice (DOJ). We interviewed medical professionals 
affiliated with the New York University School of Medicine, FDNY's 
Bureau of Health Services, Long Island Occupational and Environmental 
Health Center, Mount Sinai-Irving J. Selikoff Center for Occupational 
and Environmental Medicine, Mount Sinai School of Medicine Department 
of Psychiatry, and the University of Medicine and Dentistry of New 
Jersey's Robert Wood Johnson Medical School. We relied on data provided 
by agency officials and contained in government publications and did 
not independently verify the data we obtained. In our judgment the 
reliability of the information we obtained was adequate for our 
purposes. HHS and New York State officials provided comments on the 
facts contained in this statement, and we made changes as appropriate. 
We conducted our work from July 2005 through September 2005 in 
accordance with generally accepted government auditing standards. 

In summary, three federally funded programs implemented by state and 
local governments or private organizations in the aftermath of the WTC 
attack have provided initial medical examinations--and in some cases 
follow-up examinations--to thousands of affected responders to screen 
for health problems. For example, the FDNY program completed initial 
screening for over 15,000 firefighters and emergency medical service 
personnel, and the worker and volunteer program has screened over 
14,000 other responders. The New York State program screened about 
1,700 state responders before ending its screening examinations; in 
general, it has not informed state responders that they are now 
eligible to receive continued monitoring from the worker and volunteer 
program. These three programs and the WTC Health Registry have 
collected information that monitoring program officials believe could 
be used by researchers to help better understand the health 
consequences of the attack and improve treatment, such as by 
identifying which types of treatment are effective for specific 
conditions. Officials of programs that plan to conduct long-term health 
monitoring are concerned that current federal funding arrangements may 
be too short to allow for identification of all the health effects that 
participants may eventually experience. 

In contrast to the progress made by federally funded programs 
implemented by state and local governments or private organizations, 
the program that HHS implemented to screen federal workers who were 
sent by their agencies to respond to the WTC disaster has accomplished 
little. The program--which started later than other WTC monitoring 
programs--completed screening of 394 of the estimated 10,000 federal 
workers who responded in an official capacity to the disaster and were 
not eligible for any other WTC health monitoring program. HHS placed 
the program on hold in January 2004, when it stopped scheduling new 
examinations. It has not screened anyone since March 2004. We 
identified two federal agencies that, in the aftermath of the WTC 
attack, have implemented programs to assess the health of their own 
employees who responded to the disaster. 

Officials involved in WTC health monitoring programs cited lessons from 
their experiences that could help others who may be responsible for 
designing and implementing disaster-related health monitoring efforts 
in the future. These include the need to quickly identify and contact 
people affected by a disaster; to monitor for mental health effects, as 
well as the more obvious physical injuries and illnesses; and, when 
developing health monitoring efforts in the wake of disasters, to 
anticipate that there will likely be many people who require referrals 
for further diagnostic and treatment services and that handling the 
referral process may require a substantial level of effort. 

Background: 

When the WTC buildings collapsed on September 11, 2001, an estimated 
250,000 to 400,000 people were immediately exposed to a noxious mixture 
of dust, debris, smoke, and potentially toxic contaminants in the air 
and on the ground, such as pulverized concrete, fibrous glass, 
particulate matter, and asbestos. Those affected included people 
residing, working, or attending school in the vicinity of the WTC and 
thousands of emergency response workers. Also affected were the 
estimated 40,000 responders who were involved in some capacity in the 
days, weeks, and months that followed, including personnel from many 
government agencies and private organizations as well as other workers 
and volunteers.[Footnote 9]

A wide variety of physical and mental health effects have been observed 
and reported among people who were involved in rescue, recovery, and 
cleanup operations and among those who lived and worked in the vicinity 
of the WTC.[Footnote 10] Physical health effects included injuries and 
respiratory conditions, such as sinusitis, asthma, and a new syndrome 
called WTC cough, which consists of persistent coughing accompanied by 
severe respiratory symptoms. Almost all firefighters who responded to 
the attack experienced respiratory effects, including WTC cough, and 
hundreds had to end their firefighting careers due to WTC-related 
respiratory illnesses. The most commonly reported mental health effects 
among responders and others were symptoms associated with posttraumatic 
stress disorder--an often debilitating disorder that can develop after 
a person experiences or witnesses a traumatic event, and which may not 
develop for months or years after the event. Behavioral effects such as 
alcohol and tobacco use and difficulty coping with daily 
responsibilities were also reported. 

Several federally funded programs monitor the health of people who were 
exposed to the WTC attack and its aftermath. The monitoring programs 
vary in such aspects as eligibility requirements, methods used for 
collecting information about people's health, and approaches for 
offering referrals. Of the four programs that offer medical 
examinations to WTC responders, the only one that is open to federal 
workers who responded to the disaster in an official capacity is the 
one implemented by HHS. (See table 1.) None of the monitoring programs 
receives federal funds to provide clinical treatment for health 
problems that are identified. 

Table 1: Key Federally Funded WTC Health Monitoring Programs: 

FDNY WTC Medical Monitoring Program[A];  
Implementing agency or organization: FDNY Bureau of Health Services 
(FDNY-BHS); 
Federal administering agency: National Institute for Occupational 
Safety and Health (NIOSH); 
Eligible populations: Firefighters and emergency medical service 
technicians; 
Monitoring methods: Medical questionnaire and examination; 
Treatment referral: Refers to FDNY-BHS. 

WTC Medical Monitoring Program (worker and volunteer program)[A]; 
Implementing agency or organization: Five clinical centers, one of 
which, the Mount Sinai-Irving J. Selikoff Center for Occupational and 
Environmental Medicine, also serves as a data and coordination 
center[B]; 
Federal administering agency: NIOSH; 
Eligible populations: Rescue and recovery workers and volunteers, 
except for federal workers who were official responders and New York 
City (NYC) firefighters[C]; 
Monitoring methods: Medical questionnaire and examination; 
Treatment referral: Refers to privately funded programs available to 
responders; some privately funded treatment provided at the clinical 
centers. 

New York State responder screening program[D]; Implementing agency or 
organization: New York State Department of Health; 
Federal administering agency: National Center for Environmental Health; 
Eligible populations: New York State employees and National Guard 
personnel who responded to the WTC attack in an official capacity; 
Monitoring methods: Medical questionnaire and examination; 
Treatment referral: Instructed participants to see their primary care 
physician or a specialist. 

WTC Health Registry; Implementing agency or organization: NYC 
Department of Health and Mental Hygiene; 
Federal administering agency: Agency for Toxic Substances and Disease 
Registry (ATSDR); 
Eligible populations: Responders and people living or attending school 
in the area of the WTC, or working or present in the vicinity on 
September 11, 2001[E]; 
Monitoring methods: Telephone-based health and exposure interview; 
Treatment referral: Provides information on where treatment can be 
sought;[F] refers participants to LIFENETg for mental health services. 

WTC Federal Responder Screening Program; Implementing agency or 
organization: Department of Health and Human Services' (HHS) Office of 
Public Health Emergency Preparedness; 
Federal administering agency: HHS; 
Eligible populations: Federal workers who responded to the WTC attack 
in an official capacity; 
Monitoring methods: Medical questionnaire and examination; 
Treatment referral: Instructs participants to see their primary care 
physician; in future, may refer participants with mental health 
symptoms to a Federal Occupational Health Services employee assistance 
program. 

Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai, 
National Center for Environmental Health, New York City Department of 
Health and Mental Hygiene, New York State Department of Health, and 
NIOSH. 

[A] The FDNY WTC Medical Monitoring Program and the WTC Medical 
Monitoring Program constitute the WTC Responder Health Consortium. 
NIOSH established the consortium in March 2004 to coordinate the health 
monitoring of the two programs and to facilitate data sharing. 

[B] The other clinical centers are located at the Long Island 
Occupational and Environmental Health Center, the New York University 
School of Medicine, the City University of New York's Queens College, 
and the University of Medicine and Dentistry of New Jersey's Robert 
Wood Johnson Medical School. The responsibilities of the Mount Sinai 
data and coordination center include coordination of the clinical 
centers, outreach and education, quality assurance, and data 
management. 

[C] The worker and volunteer program excludes responders who were paid 
as federal workers or as NYC firefighters for their WTC work; these 
employees are eligible for other programs. The program initially 
excluded responders who were paid as New York State employees for their 
WTC work and were eligible for the New York State responder screening 
program. That program ended its screening examinations in November 
2003, and as of February 2005, New York State responders became 
eligible for the worker and volunteer program. 

[D] The New York State program ended its screening examinations in 
November 2003. 

[E] Participants in the other WTC monitoring programs may also 
participate in the registry program. 

[F] The registry program provides enrollees with a resource guide of 
occupational, respiratory, environmental, and mental health facilities 
where they could seek treatment. Some of the services provided by these 
facilities require payment, while others are free of charge. 

[G] LIFENET is a 24-hour mental health information and referral service 
provided by the New York State Office of Mental Health. In cases where 
WTC Health Registry interviewers think a person is experiencing 
moderate distress, they can immediately transfer the call so the person 
can speak to a LIFENET counselor. 

[End of table]

The majority of federal funding for these monitoring programs was 
provided by DHS's Federal Emergency Management Agency (FEMA),[Footnote 
11] as part of the approximately $8.8 billion in federal assistance 
that the Congress appropriated to FEMA for response and recovery 
activities after the WTC disaster.[Footnote 12] One fiscal year 2003 
appropriation specifically authorized FEMA to use a portion of its WTC- 
related funding for screening and long-term monitoring of emergency 
services and rescue and recovery personnel.[Footnote 13] Generally, 
however, FEMA may fund only short-term care after a disaster, such as 
emergency medical services, and not ongoing clinical 
treatment.[Footnote 14]

FEMA entered into interagency agreements with HHS to fund most of these 
health monitoring programs. HHS is the designated lead agency for the 
public health and medical support function under the National Response 
Plan and is responsible for coordinating the medical resources of all 
federal departments and agencies. HHS's Office of Public Health 
Emergency Preparedness (OPHEP) coordinates and directs HHS's emergency 
preparedness and response program. 

Health Monitoring Programs Implemented by State and Local Governments 
or Private Organizations Have Made Progress: 

Three federally funded programs implemented by state and local 
governments or private organizations--the FDNY WTC Medical Monitoring 
Program, WTC Medical Monitoring Program (worker and volunteer program), 
and New York State responder screening program--have made progress in 
monitoring the physical and mental health of people affected by the WTC 
attack. Federal employees who responded to the WTC disaster in an 
official capacity were not eligible for these programs because it was 
expected that another program would be developed for them. The New York 
State program stopped providing examinations in November 2003, and 
state workers are now eligible for initial or continued monitoring 
through the worker and volunteer program. In general, the state program 
has not informed state responders that they are eligible for the worker 
and volunteer program. All three programs and the WTC Health Registry 
have collected information that could contribute to better 
understanding of the health consequences of the attack and improve 
health care for affected individuals. Officials from the FDNY, worker 
and volunteer, and WTC Health Registry programs are concerned that 
federal funding for their programs could end before sufficient 
monitoring occurs to identify all long-term health problems related to 
the WTC disaster. 

Three WTC Monitoring Programs Provided Medical Examinations to Identify 
Responders' Health Problems: 

Three federally funded programs implemented by state and local 
governments or private organizations have provided medical examinations 
to identify physical and mental health problems after the WTC attack. 
(See table 2.) Two of these programs--the FDNY WTC Medical Monitoring 
Program and the worker and volunteer program--are tracking the health 
of WTC rescue, recovery, and cleanup workers and volunteers over time. 
The third program, the New York State responder screening program, 
offered one-time screening examinations to state employees, including 
National Guard personnel, who participated in WTC rescue, recovery, and 
cleanup work. Federal employees who responded to the WTC disaster in an 
official capacity were not eligible for any of these programs because 
it was expected that another program would be developed for them. 

Table 2: Monitoring Activities and Associated Federal Funding for WTC 
Monitoring Programs Implemented by State and Local Governments or 
Private Organizations: 

FDNY WTC Medical Monitoring Program; 
Completed monitoring activities: Through June 2005, 15,284 firefighters 
and emergency medical service technicians received screening 
examinations, and 522 of these participants completed a follow-up 
examination; 
Planned monitoring activities: By June 2009, conduct three follow-up 
examinations of each participant; 
Federal funding[A]: $4.8 million was provided beginning in October 2001 
for initial program; additional $25 million is available through June 
2009. 

WTC Medical Monitoring Program (worker and volunteer program); 
Completed monitoring activities: Through June 2005, 14,110 people 
received screening examinations, and 1,699 of these participants 
completed a follow-up examination; 
Planned monitoring activities: By July 2009, conduct three follow-up 
examinations of each participant; 
Federal funding[A]: $15.9 million was provided for initial program;[B] 
additional $56 million is available through July 2009. 

New York State responder screening program; 
Completed monitoring activities: As of November 2003, 1,677 of 
approximately 9,800 eligible employees and National Guard personnel 
received screening examinations; 
Planned monitoring activities: No further examinations are planned. 
Participants are now eligible to participate in the worker and 
volunteer program; 
Federal funding[A]: $2.4 million was provided in January 2002 and is 
available through January 2006.[C]. 

WTC Health Registry; 
Completed monitoring activities: As of November 2004, the program 
completed baseline data collection through interviews with the 71,437 
people who enrolled in the registry;[D] registry officials estimate 
that about 385,000 people had been eligible to enroll. In 2005, the 
program updated contact information obtained at the time of enrollment; 
Planned monitoring activities: In 2006, conduct follow-up survey of 
participants; Registry officials are developing plans to track 
participants' health through 2023; 
Federal funding[A]: $20 million was provided beginning in July 2002,[E] 
and additional funding of about $3 million has since been provided.f. 

Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai, 
National Center for Environmental Health, New York City Department of 
Health and Mental Hygiene, New York State Department of Health, and 
NIOSH. 

[A] Except as noted, FEMA provided these funds to the federal 
administering agency for each monitoring program. 

[B] $11.8 million of this amount was provided beginning in July 2002 
through funds appropriated to CDC. An additional $4.1 million was 
provided in fiscal year 2003 through an interagency agreement with 
FEMA. 

[C] The primary program activity since November 2003 has been data 
analysis. 

[D] Registry officials told us that final enrollment numbers may be 
revised pending internal verification of data. 

[E] The grant agreement is between ATSDR and the New York City 
Department of Health and Mental Hygiene. However, ATSDR contracted 
directly with Research Triangle Institute (RTI), a private not-for- 
profit organization, for most of the work to establish the registry, 
and about $16 million of the $20 million went directly from ATSDR to 
RTI. 

[F] The Environmental Protection Agency provided $2 million of these 
funds. In addition, CDC and ATSDR provided $500,000 each. 

[End of table]

The FDNY program completed initial screening for over 15,000 
firefighters and emergency medical service personnel, and the worker 
and volunteer program completed initial screening for over 14,000 other 
responders. In both programs, screenings include physical examinations, 
pulmonary function tests, blood and urine analysis, a chest X-ray, and 
questionnaires on exposures and mental health issues. Both programs 
have begun to conduct follow-up examinations of participants and 
continue to accept new enrollees who desire initial screening. Current 
plans are to conduct a total of three follow-up examinations for each 
participant by 2009. As part of their federally funded activities, both 
programs provide referrals for participants who require treatment. FDNY 
employees and retirees can obtain treatment and counseling services 
from the FDNY Bureau of Health Services and the FDNY Counseling 
Services Unit, or they can use their health insurance to obtain 
treatment and counseling services elsewhere. The worker and volunteer 
program also provides referrals for its participants, including 
referrals to programs funded by the American Red Cross and other 
nonprofit organizations. 

The New York State program screened about 1,700 of the estimated 9,800 
state workers and National Guard personnel who responded to the WTC 
disaster. Officials sent letters to these responders to inform them 
about the program and their eligibility for it.[Footnote 15] For each 
participant, the screening included a health and exposure questionnaire 
and physical and pulmonary examinations. Participants who required 
further evaluation or treatment after screening were told to follow up 
with their personal physician or a specialist. The program stopped 
screening participants in November 2003, in part because the number of 
responders requesting examinations was dwindling, and no follow-up 
examinations are planned. 

In February 2005, worker and volunteer program officials began to allow 
New York State responders to participate in that monitoring program. 
The officials determined that the worker and volunteer program would 
have sufficient funding to accommodate state workers who want to join 
the program.[Footnote 16] The state program has not notified the 
approximately 1,700 workers it has screened that they are now eligible 
for continued monitoring from the worker and volunteer program. Program 
officials relayed this development only to those state responders who 
inquired about screening or monitoring examinations following the 
decision to permit state responders to participate in the worker and 
volunteer program. Worker and volunteer program officials told us that, 
through August 2005, no state workers who responded to the WTC disaster 
in an official capacity had received examinations from the worker and 
volunteer program. According to worker and volunteer program officials, 
any state worker screened by the state program would need a new 
baseline examination through the worker and volunteer program because 
the screening data collected by the state program differ from the data 
collected in the worker and volunteer program. For example, the worker 
and volunteer program offers a breathing test not provided by the state 
program. 

Programs Provide Data for WTC-Related Health Research: 

In addition to providing medical examinations, these three programs-- 
the FDNY program, the worker and volunteer program, and the New York 
State program--have collected information for use in scientific 
research to better understand the health consequences of the WTC attack 
and other disasters. A fourth program, the WTC Health Registry, 
includes health and exposure information obtained through interviews 
with participants; it is designed to track participants' health for 20 
years and to provide data on the long-term health consequences of the 
disaster (see table 2). Physicians who evaluate and treat WTC 
responders told us they expect that research on health effects from the 
disaster will not only help researchers understand the health 
consequences, but also provide information on appropriate treatment 
options for affected individuals. 

Both the FDNY program and the worker and volunteer program have been 
the basis for published research articles on the health of WTC 
responders. For example, the FDNY program reported on the injuries and 
illnesses experienced by firefighters and emergency medical service 
workers after responding to the attack.[Footnote 17] In addition, the 
worker and volunteer program published information on the physical and 
mental health of responders in 2004.[Footnote 18] Officials from both 
programs plan to publish additional findings as they track 
participants' health over time. Although the New York State program has 
stopped offering examinations, program officials are continuing to 
analyze data from the program with plans for eventual publication. 

The WTC Health Registry program has collected health information 
through interviews with responders, people living or attending school 
in the vicinity of the WTC site, and people working or present in the 
vicinity on September 11, 2001. The registry completed enrollment and 
conducted interviews with over 71,000 participants by November 2004. 
Officials updated contact information for all participants in 2005, and 
they plan to conduct a follow-up health survey of participants in early 
2006. Registry officials would like to conduct subsequent follow-up 
surveys periodically through about 2023--20 years after the program 
began in 2003--but have not yet secured funding for long-term 
monitoring.[Footnote 19]

The registry is designed to provide a basis for research to evaluate 
the long-term health consequences of the disaster. It includes contact 
information for people affected by the WTC attack, information on 
individuals' experiences and exposures during the disaster, and 
information on their health. In November 2004, registry officials 
published preliminary results on the health status of registry 
participants, and officials expect to submit several research papers 
for publication within the next year. In addition, in May 2005, 
registry officials published guidelines for allowing registry 
information to be used in scientific research,[Footnote 20] and they 
have since approved three proposals for external research projects that 
use registry information. These proposals include two studies of 
building evacuations and a study of psychological responses to 
terrorism. 

Program Officials Are Concerned That Current Federal Funding 
Arrangements Will End before Needed Monitoring Is Complete: 

Officials from the FDNY, worker and volunteer, and WTC Health Registry 
programs are concerned that current federal funding arrangements for 
programs designed to track participants' health over time may be too 
short to allow for identification of all the health effects that may 
eventually develop. ATSDR plans to fund the WTC Health Registry through 
April 2008, and NIOSH plans to fund the FDNY program and the worker and 
volunteer program through mid-2009. ATSDR's 5-year cooperative 
agreement with the New York City Department of Health and Mental 
Hygiene to support the WTC Health Registry went into effect April 30, 
2003, and extends through April 29, 2008. Similarly, NIOSH awarded 5- 
year grants in July 2004 to continue the FDNY and worker and volunteer 
programs, which had begun in 2001 and 2002, respectively. Health 
experts involved in these monitoring programs, however, cite the need 
for long-term monitoring of affected groups because some possible 
health effects, such as cancer, may not appear until decades after a 
person has been exposed to a harmful agent. They also told us that 
monitoring is important for identifying and assessing the occurrence of 
newly identified conditions, such as WTC cough, and chronic conditions, 
such as asthma. 

HHS's Program for Screening Federal Responders Has Accomplished Little 
and Is on Hold: 

HHS's OPHEP established the WTC Federal Responder Screening Program to 
provide medical screening examinations for an estimated 10,000 federal 
workers who responded to the WTC disaster in an official capacity and 
were not eligible for any other medical monitoring program. OPHEP did 
not develop a comprehensive list of federal responders who were 
eligible for the program. The program began in June 2003--about a year 
later than other monitoring programs--and completed screenings for 394 
workers. No examinations have occurred since March 2004, because 
officials placed the program on hold, temporarily suspending new 
examinations. The program is still on hold, and OPHEP officials are 
taking actions intended to lead to restarting the program. We 
identified two federal agencies that established screening programs for 
their own personnel who responded to the disaster. 

HHS Program Screened Few Federal Workers and Has Been on Hold for over 
1 Year: 

HHS's WTC Federal Responder Screening Program was established to 
provide free voluntary medical screening examinations for an estimated 
10,000 federal workers[Footnote 21] whom their agencies sent to respond 
to the WTC disaster from September 11, 2001, through September 10, 
2002, and who were not eligible for any other monitoring 
program.[Footnote 22] FEMA provided $3.74 million through an 
interagency agreement with HHS's OPHEP for the purpose of developing 
and implementing the program. OPHEP entered into an agreement with 
HHS's FOH to schedule and conduct the screening examinations. 

The launching of the federal responder screening program lagged behind 
the implementation of other federally funded monitoring programs for 
WTC responders. For example, the medical screening program for New York 
State employees and the worker and volunteer program started conducting 
screening examinations in May 2002 and July 2002, respectively. 
However, OPHEP did not launch its program until June 2003. (Figure 1 
highlights key actions in developing and implementing the program.)

Figure 1: Timeline of Key Actions Related to WTC Federal Responder 
Screening Program: 

[See PDF for image]

[End of figure]

OPHEP did not develop a plan for identifying all federal agencies and 
their personnel that responded to the WTC disaster or for contacting 
all federal personnel eligible for the screening program. Although 
OPHEP and FEMA developed a partial list of federal responders-- 
consisting primarily of HHS and FEMA personnel--OPHEP did not have a 
comprehensive list of agencies and personnel, and so could not inform 
all eligible federal responders about the WTC screening program. The 
program's principal action to communicate with the federal responders 
was to place program information and registration forms on FEMA's 
National Disaster Medical System (NDMS) Web site.[Footnote 23]

The screening program had operated for about 6 months when OPHEP 
officials decided in January 2004 to place it on hold by temporarily 
suspending examinations. FOH officials told us that they completed 394 
screening examinations[Footnote 24] from June 2003 through March 
2004,[Footnote 25] with most completed by the end of September 2003. 
According to FOH, a total of $177,967 was spent on 
examinations.[Footnote 26] As of September 7, 2005, the program 
remained on hold, with 37 people on the waiting list for 
examinations,[Footnote 27] and OPHEP has not set a date for resuming 
the examination process. 

OPHEP officials told us that three operational issues contributed to 
the decision to suspend the program. First, OPHEP could not inform all 
eligible federal responders about the program because it lacked a 
comprehensive list of eligible federal responders. Second, there were 
concerns about what actions FOH clinicians could take when screening 
examinations identified problems. Based on the examinations that had 
been completed before the program was placed on hold, FOH clinicians 
determined that many participants needed additional diagnostic testing 
and follow-up care, primarily in the areas of respiratory functioning 
and mental health. However, under the existing interagency agreement 
there was no provision for providing follow-up care and no direction 
for clinicians on how to handle the provision of further diagnostic 
tests, treatment, or referrals. FOH officials told us that they were 
concerned about continuing to provide screening examinations without 
the ability to provide participants with additional needed services. 
Third, although the screening program had been established to provide 
examinations to all federal responders regardless of their current 
federal employment status, HHS officials told us that the department 
determined that FOH does not have the authority to provide examinations 
to people who are no longer in federal service. OPHEP officials told us 
in September 2005 that they were exploring avenues for providing 
examinations to federal responders who were no longer federal 
employees. 

OPHEP has begun to take action to prepare for offering examinations 
again. In April 2005, program officials enlisted the assistance of 
ATSDR--which had successfully developed the WTC Health Registry--to 
help develop the needed lists of federal agencies and personnel for the 
federal responder program. OPHEP executed an agreement with ATSDR that 
allocated about $491,000 from the program's remaining allocation from 
FEMA to ATSDR.[Footnote 28] Under this agreement, which is scheduled to 
run through April 2006, ATSDR is working with the contractor it used to 
develop the WTC Health Registry to develop a new registration Web site, 
develop and implement a comprehensive recruitment and enrollment plan 
for current and former federal workers, and establish a database 
containing the names of federal responders. On September 1, 2005, OPHEP 
sent a letter to 51 federal agencies requesting them to provide ATSDR's 
contractor with contact information on the employees they sent to 
respond to the WTC disaster. 

In July 2005, OPHEP and FOH executed a new agreement so that when the 
program begins examining responders again, FOH clinicians will be able 
to make referrals for follow-up care. For example, they will be able to 
refer participants with mental health symptoms to an FOH employee 
assistance program for a telephone assessment. If appropriate, the 
participant will be referred to an employee assistance program 
counselor for up to six in-person sessions. If the assessment indicates 
that longer treatment is necessary, the participant instead will be 
advised to use health insurance to obtain care or to contact a local 
Department of Labor Office of Workers' Compensation to file a claim, 
receive further evaluation, and possibly obtain compensation for mental 
health services. The new agreement between OPHEP and FOH also will 
allow FOH clinicians to order additional clinical tests, such as 
special pulmonary and breathing tests. 

Two Federal Agencies Established Their Own Screening Programs: 

We identified two federal agencies that established medical screening 
programs to assess the health of the personnel they had sent to respond 
to the WTC disaster. One agency, the Army, established two screening 
programs--one specifically for Army Corps of Engineers personnel and 
one that also included other Army responders. The Army Corps of 
Engineers established a voluntary program to assess the health of 356 
employees it had sent to respond to the disaster.[Footnote 29] The 
program, initiated in November 2001, consists of sending employees an 
initial medical screening questionnaire covering physical health 
issues.[Footnote 30] If questionnaire results indicate symptoms or 
concerns that need further evaluation, the employee is offered a 
medical examination.[Footnote 31] As of August 2004, 92 Corps of 
Engineers employees had participated in the program, with 40 receiving 
follow-up examinations. The Army's Center for Health Promotion and 
Preventive Medicine initiated a program--the World Trade Center Support 
Health Assessment Survey--in January 2002. It was designed as a 
voluntary medical screening for Army military and civilian personnel, 
including contractors. From January 2002 through September 2003, 
questionnaires were sent to 256 employees.[Footnote 32] According to 
DOD, 162 employees completed and returned their questionnaires. In 
addition, the U.S. Marshals Service, within the Department of Justice, 
modified an existing agreement with FOH in 2003 for FOH to screen 
approximately 200 U.S. Marshals Service employees assigned to the WTC 
or Pentagon recovery sites. The one-time assessment includes a 
screening questionnaire and a medical examination.[Footnote 33] FOH 
officials said that as of August 2005, 88 of the 200 U.S. Marshals 
Service employees had requested and obtained examinations.[Footnote 34]

Lessons from WTC Health Monitoring Programs Could Assist Future 
Monitoring Efforts: 

Officials involved in the WTC health monitoring programs implemented by 
state and local governments or private organizations--including 
officials from the federal administering agencies--derived lessons from 
their experiences that could help officials design such programs in the 
future. They include the need to quickly identify and contact people 
affected by a disaster, the value of a centrally coordinated approach 
for assessing individuals' health, the importance of monitoring both 
physical and mental health, and the need to plan for providing 
referrals for treatment when screening examinations identify health 
problems. 

Officials involved in the monitoring programs emphasized the importance 
of quickly identifying and contacting people affected by a disaster. 
They said that potential monitoring program participants can become 
more difficult to locate as time passes.[Footnote 35] In addition, 
potential participants' ability to recall the events of a disaster may 
decrease over time, making it more difficult to collect accurate 
information about their experiences and health. However, the time it 
takes to design, fund, approve, and implement monitoring programs can 
lead to delays in contacting the people who were affected. For example, 
the WTC Health Registry received funding in July 2002 but did not begin 
collecting data until September 2003--2 years after the disaster. From 
July 2002 through September 2003, the program's activities included 
developing the registry protocol, testing the questionnaire, and 
obtaining approval from institutional review boards and the federal 
Office of Management and Budget.[Footnote 36] This delayed the 
collection of information from participants. To prevent similar delays 
during the response to future disasters, ATSDR officials are developing 
a questionnaire, known as the Rapid Response Registry, to allow 
officials to identify and locate potentially affected individuals 
immediately after a disaster and collect basic preliminary information, 
such as their current contact information and their location during the 
disaster.[Footnote 37] ATSDR officials expect that using this 
instrument would reduce delays in collecting time-sensitive information 
while officials take the time necessary to develop a monitoring program 
for disaster-related health effects. 

Furthermore, officials told us that health monitoring for future 
disasters could benefit from additional centrally coordinated planning. 
Such planning could facilitate the collection of compatible data among 
monitoring efforts, to the extent that this is appropriate. Collecting 
compatible data could allow information from different programs to be 
integrated and contribute to improved data analysis and more useful 
research. In addition, centrally coordinated planning could help 
officials determine whether separate programs are necessary to serve 
different groups of people. For example, worker and volunteer program 
officials indicated that it might have been possible for that program 
to serve federal workers who responded to the disaster in an official 
capacity, which might have eliminated the need to organize and 
administer a separate program for them. 

Officials also stated that screening and monitoring programs should be 
comprehensive, encompassing both physical and mental health 
evaluations. Worker and volunteer medical monitoring program officials 
told us that the initial planning for the program had focused primarily 
on screening participants' physical health, and that they did not 
originally budget for extensive mental health screening. Subsequently, 
they recognized a need for more extensive mental health screening, 
including greater participation of mental health professionals, but the 
program's federal funding was not sufficient to cover such screening. 
By collaborating with the Mount Sinai School of Medicine Department of 
Psychiatry, program officials were able to obtain philanthropic funding 
to develop a more comprehensive mental health questionnaire, provide on-
site psychiatric screening, and, when necessary, provide more extensive 
evaluations. 

Many participants in the monitoring programs required additional 
testing or needed treatment for health problems that were identified 
during screening examinations. Officials told us that finding treatment 
sources for such participants is an important, but challenging, part of 
the programs' responsibility. For example, officials from the worker 
and volunteer program stated that identifying providers available to 
treat participants became a major part of their operations, and was 
especially difficult when participants lacked health insurance. The 
officials said that planning for future monitoring programs should 
include a determination of how best to help participants obtain needed 
treatment. 

Concluding Observations: 

Federally funded programs implemented by state and local governments or 
private organizations to monitor the health effects of the WTC attack 
on thousands of people who responded to the disaster have made 
progress. However, the program HHS established to screen the federal 
employees whose agencies sent them to the WTC after the attack has 
accomplished little, completing screenings of fewer than 400 of the 
thousands of federal responders. Moreover, no examinations have 
occurred for over a year. Because of this program's limited activity, 
and the inability of federal workers to participate in other monitoring 
programs because of the assumption that they would have the opportunity 
to receive screening examinations through the HHS program, many federal 
responders may not have had an opportunity to identify and seek 
treatment for health problems related to the WTC disaster. For state 
responders, the opportunity for continued monitoring could be lost if 
they are not informed that they are now eligible to participate in the 
worker and volunteer program. 

Based on their experiences, officials involved in the monitoring 
programs have made a number of useful observations that will apply to 
future terrorist attacks and natural disasters such as Hurricane 
Katrina. For example, screening for mental as well as physical health 
problems in New Orleans and along the Gulf Coast will be critical to 
the recovery of survivors of Hurricane Katrina and the responders to 
the disaster. The federal, state, and local government officials who 
are responsible for planning and implementing health monitoring 
activities in the aftermath of disasters could improve their 
effectiveness by incorporating the lessons learned from the World Trade 
Center experience. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other Members of the Subcommittee may 
have at this time. 

Contact and Acknowledgments: 

For further information about this testimony, please contact Cynthia A. 
Bascetta at (202) 512-7101 or bascettac@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. Helene F. Toiv, Assistant Director; 
George H. Bogart; Alice L. London; Roseanne Price; and William R. 
Simerl made key contributions to this statement. 

[End of section]

Appendix I: Abbreviations: 

ATSDR: Agency for Toxic Substances and Disease Registry:
CDC: Centers for Disease Control and Prevention: 
DHS: Department of Homeland Security: 
DOD: Department of Defense: 
DOJ: Department of Justice: 
FDNY: New York City Fire Department: 
FDNY-BHS: New York City Fire Department Bureau of Health Services: 
FEMA: Federal Emergency Management Agency: 
FOH: Federal Occupational Health Services:
HHS: Department of Health and Human Services: 
NDMS: National Disaster Medical System: 
NIOSH: National Institute for Occupational Safety and Health: 
NYC: New York City: 
OPHEP: Office of Public Health Emergency Preparedness: 
RTI: Research Triangle Institute: 
WTC: World Trade Center: 

[End of section]

Appendix II: Government Agencies That Sent Responders Following the 
World Trade Center Attack: 

Through our work, we identified the following agencies that sent 
employees to respond to the World Trade Center attack of September 11, 
2001. 

Federal Agencies: 

Department of Defense: 
Department of Energy: 
Department of Health and Human Services: Agency for Toxic Substances 
and Disease Registry: 
Department of Health and Human Services: Centers for Disease Control 
and Prevention: 
Department of Health and Human Services: National Institutes of Health: 
Department of Health and Human Services: Substance Abuse and Mental 
Health Services Administration: 
Department of Homeland Security: Federal Emergency Management 
Agency[Footnote 38]: 
Department of Homeland Security: U.S. Coast Guard[Footnote 39]: 
Department of the Interior: National Park Service: 
Department of Justice: Federal Bureau of Investigation: 
Department of Justice: U.S. Marshals Service: 
Department of Labor: Occupational Safety and Health Administration 
Environmental Protection Agency: 

New York State Agencies: 

Department of Environmental Conservation: 
Department of Health: 
Division of Military and Naval Affairs: 
Emergency Management Office: 
Office of Mental Health: 

New York City Agencies: 

Department of Design and Construction: 
Department of Environmental Protection: 
Department of Health and Mental Hygiene: 
Department of Sanitation: 
Fire Department: 
Metropolitan Transportation Authority: 
Office of Emergency Management: 
Police Department: 

[End of section] 

FOOTNOTES

[1] A list of abbreviations used in this testimony is in app. I. 

[2] In this testimony, the term "responders" refers to anyone involved 
in rescue, recovery, or cleanup activities at or near the vicinity of 
the WTC site and Staten Island Fresh Kills landfill (the off-site 
location of the WTC recovery operation). 

[3] See, for example, Centers for Disease Control and Prevention, 
"Mental Health Status of World Trade Center Rescue and Recovery Workers 
and Volunteers--New York City, July 2002-August 2004," Morbidity and 
Mortality Weekly Report, vol. 53 (2004); Centers for Disease Control 
and Prevention, "Physical Health Status of World Trade Center Rescue 
and Recovery Workers and Volunteers--New York City, July 2002-August 
2004," Morbidity and Mortality Weekly Report, vol. 53 (2004); and 
Gisela I. Banauch and others, "Bronchial Hyperreactivity and Other 
Inhalation Lung Injuries in Rescue/Recovery Workers after the World 
Trade Center Collapse," Critical Care Medicine, vol. 33, no. 1 (2005). 

[4] See, for example, GAO, September 11: Health Effects in the 
Aftermath of the World Trade Center Attack, GAO-04-1068T (Washington, 
D.C.: Sept. 8, 2004); GAO, Bioterrorism: Public Health Response to 
Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 
2003); GAO, Public Health Preparedness: Response Capacity Improving, 
but Much Remains to Be Accomplished, GAO-04-458T (Washington, D.C.: 
Feb. 12, 2004); and Institute of Medicine, Preparing for the 
Psychological Consequences of Terrorism: A Public Health Strategy 
(Washington, D.C.: 2003). 

[5] This program was formerly known as the WTC Worker and Volunteer 
Medical Screening Program. In this testimony, we refer to the program 
as the worker and volunteer program. 

[6] In this testimony, we use the term monitoring program to refer to 
both one-time screening programs and programs that include initial 
screening and periodic follow-up monitoring. 

[7] The DHS officials we spoke with were from the Federal Emergency 
Management Agency, which became part of DHS in March 2003. 

[8] FOH is a part of HHS's Program Support Center. 

[9] The responders included firefighters, law enforcement officers, 
emergency medical technicians and paramedics, morticians, health care 
professionals, and other workers and volunteers, including those in the 
construction and ironwork trades, heavy equipment operators, mechanics, 
engineers, truck drivers, carpenters, day laborers, and 
telecommunications workers. Numerous federal, state, and New York City 
agencies sent personnel to respond to the WTC disaster (see app. II). 

[10] GAO-04-1068T. 

[11] FEMA is the agency responsible for coordinating federal disaster 
response efforts under the National Response Plan. 

[12] FEMA provided funds to HHS to support screening and long-term 
monitoring efforts from funds appropriated for disaster relief and 
emergency response to the September 11, 2001, terrorist attacks. See 
Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7, 117 
Stat. 11, 517; 2002 Supplemental Appropriations Act for Further 
Recovery from and Response to Terrorist Attacks on the United States, 
Pub. L. No. 107-206, 116 Stat. 820, 894; Department of Defense and 
Emergency Supplemental Appropriations for Recovery from and Response to 
Terrorist Attacks on the United States Act, 2002, Pub. L. No. 107-117, 
115 Stat. 2230, 2338; and 2001 Emergency Supplemental Appropriations 
Act for Recovery from and Response to Terrorist Attacks on the United 
States, Pub. L. No. 107-38, 115 Stat. 220-221. 

[13] Pub. L. No. 108-7. 

[14] The Robert T. Stafford Disaster Relief and Emergency Assistance 
Act, as amended, authorizes FEMA to, among other things, make 
appropriated funds available for disaster relief and emergency 
assistance. Pub. L. No. 93-288, 88 Stat. 143 (1974), as amended. The 
Stafford Act does not specifically authorize ongoing clinical 
treatment. 

[15] When state officials contacted the estimated 9,800 state 
responders, some of them informed the program that they were not 
interested in participating. Officials sent follow-up letters to state 
employees who did not respond to the initial mailing. National Guard 
personnel were sent only an initial letter. 

[16] As of September 1, 2005, the worker and volunteer program was in 
the process of establishing a network of providers to serve responders 
outside the New York City metropolitan area. State responders had been 
eligible for monitoring at existing New York City area clinics since 
February 2005, but they will not be able to visit providers in Albany 
and other areas of New York until the network is established. 

[17] See, for example, CDC, "Injuries and Illnesses among New York City 
Fire Department Rescue Workers after Responding to the World Trade 
Center Attacks," Morbidity and Mortality Weekly Report, vol. 51 (2002), 
and Elizabeth M. Fireman and others, "Induced Sputum Assessment in NYC 
Firefighters Exposed to World Trade Center Dust," Environmental Health 
Perspectives, vol. 112 (2004). 

[18] CDC, Morbidity and Mortality Weekly Report, vol. 53, p. 807, and 
CDC, Morbidity and Mortality Weekly Report, vol. 53, p. 812. 

[19] Program officials told us that the registry was designed as a 20- 
year program because most long-term health effects that might result 
from the WTC disaster would likely begin to appear in the population 
within that period of time. 

[20] Under the guidelines, a review committee consisting of public 
health scientists and stakeholder representatives evaluates each 
proposed research project based on criteria such as the proposal's 
scientific and technical merit, funding, and contribution to a 
community or individuals. 

[21] For this program, a federal worker is defined as being either a 
permanent, temporary, or intermittent federal employee. 

[22] According to a FEMA official, federal workers who did not receive 
official orders from their agencies to respond to the WTC disaster are 
not eligible for this program. According to an official of the worker 
and volunteer program, federal workers who volunteered on their own in 
the aftermath of the disaster were eligible to participate in that 
screening program. 

[23] NDMS provides medical care to victims and responders to domestic 
disaster, including acts of terrorism and natural disasters. According 
to HHS officials, when NDMS was transferred to FEMA in 2003 as part of 
the formation of DHS, key NDMS staff involved in the initial planning 
of the screening program were also transferred. During the transition 
period, these NDMS staff continued to carry out some tasks related to 
the screening program, including working to identify agencies that had 
sent employees to the WTC disaster, developing a list of federal 
responders, and placing information about the program on the NDMS Web 
site. Officials said that overall program management responsibility and 
funding remained with HHS. 

[24] FOH officials told us that although FOH clinicians had seen 
approximately 460 federal personnel, not all of them completed the 
entire examination process. 

[25] FOH continued to schedule and conduct examinations for those 
people who had requested an examination before the program was placed 
on hold in January 2004. 

[26] FOH officials told us that this amount includes spending on the 
394 completed examinations and on examinations that were not completed. 

[27] FOH officials told us that these 37 applications were received 
after the screening program was placed on hold in January 2004. 

[28] According to OPHEP, as of August 22, 2005, about $3 million of the 
original $3.74 million allocated by FEMA for this screening program 
remained. 

[29] The screening program has no closing date, and employees can 
request a screening examination at any time. 

[30] The questionnaire collects information on prior and WTC-related 
occupational exposures and prior and current physical health status. 

[31] The medical examination includes a comprehensive history and 
physical examination, chest X-ray, and pulmonary function, blood, and 
urine tests. 

[32] The Army's questionnaire was distributed to active-duty service 
members, activated members of the Reserves and National Guard, civilian 
employees, and civilian contractors. These included 125 New Jersey Army 
National Guard members. The 474 active-duty members of the New York 
Army National Guard who responded to the WTC disaster were not included 
due to their eligibility to participate in the medical screening 
program established for New York State workers. 

[33] The medical examination includes an occupational exposure history 
and physical examination, chest X-ray, blood and urine tests, pulmonary 
function test, audiogram, and electrocardiogram. 

[34] FOH officials told us that under the terms of the agreement, 
eligible employees can still request a screening examination. 

[35] The extent of the challenge of locating potential participants 
varied among WTC monitoring programs, depending on the population 
involved. For example, FDNY had contact information for all potential 
participants in its monitoring program because they were employed by 
FDNY during or after the disaster. In contrast, the worker and 
volunteer program and the WTC Health Registry had to expend 
considerable effort to identify people who were eligible to participate 
and inform them about the programs. 

[36] Institutional review boards are groups that have been formally 
designated to review and monitor biomedical research involving human 
subjects. Under the Paperwork Reduction Act, agencies are required to 
submit proposed information collections to the Office of Management and 
Budget for approval. See, 44 U.S.C. § 3507. 

[37] The Rapid Response Registry has been approved by CDC's 
Institutional Review Board and has undergone initial review by the 
Office of Management and Budget. 

[38] At the time of the World Trade Center attack, the Federal 
Emergency Management Agency was an independent agency. 

[39] At the time of the World Trade Center attack, the U.S. Coast Guard 
was in the Department of Transportation.